Managing progressive renal disease before dialysis

OBJECTIVE To enhance awareness of issues affecting patients with chronic re nal failure and to provide guidance for primary care practitioners managing such patients. QUALITY OF EVIDENCE Randomized trials establish the efficacy of blood press ure control and angiotensin-converting enzyme (ACE) inhibition in slowing t he progression of chronic renal disease. Some randomized trials and many pr ospective studies address management of anemia, hyperparathyroidism,; and m ultidisciplinary predialysis care. The benefits of lipid lowering are sugge sted by randomized trials among patients without renal disease. MAIN MESSAGE Progression of renal failure, particularly ih patients with pr oteinuria, can be slowed by lowering blood pressure. Angiotensin-converting enzyme inhibitors are more beneficial than other antihypertensives in this situation. Partial correction of anemia with iron, erythropoietin, or andr ogens can improve quality of life and potentially prevent cardiac disease. Renal bone disease and secondary hyperparathyroidism can be prevented in pa rt by early dietary phosphate restriction, use of calcium-containing phosph ate binders, and activated vitamin D. Correction of acidosis could improve protein metabolism and bone and cardiovascular health. Treatment of hyperli pidemia might reduce cardiovascular disease. Early involvement of a nephrol ogy-based multidisciplinary team has the potential to reduce morbidity and costs, enhance patients' knowledge of their condition, and prolong the peri od before dialysis is required. CONCLUSIONS Care of patients with progressive renal failure is complex and requires attention to detail. Family doctors play a vital role in these eff orts and should be involved in all aspects of care.